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1 Comparison of radiation dose and imaging performance for the standard Varian x-ray tube and the Richardson Healthcare ALTA750 replacement tube for the Toshiba Aquillion CT scanners. by Robert L. Dixon, Ph.D., FACR, FAAPM President, Radiological Physics Consultants, Inc. Professor Emeritus, Dept of Radiology Wake Forest University School of Medicine Winston-Salem, NC Designated US CT Expert IEC 62B MT30 CT Committee April 2018 I. Methodology On April 9, 10 we visited the Richardson Healthcare service training facility in Fort Mill, SC which has a Toshiba Aquillion-64 CT scanner in which a new standard Varian CXB-750D/4A (S/N Q7) x-ray tube was installed for our testing purposes and a service calibration performed. After making a series of measurements with the Varian tube, the tube was replaced with a new Richardson Electronics ALTA750 replacement tube from the factory (S/N ABD002H). After installation and re-calibration, the measurements were repeated. In short, same Aquillion-64 CT scanner, same dosimetry system two different x-ray tubes. (These dose results should also apply to the Aquillion-16 and 32 scanners since the same x-ray tube is used therein and the same Toshiba Dose specifications apply.) II. Measurements Radiation Dose: The same set of measurements were made on both tubes to compare the radiation dose delivered (CTDI) for a series of techniques specified by Toshiba for acceptance testing as outlined below. Image performance: A complete American College of Radiology (ACR) accreditation test was run on the scanner for both the Varian and Richardson tubes which includes additional dose measurements for typical clinical techniques. A separate resolution test was also performed.

2 Radiation Dose Results Table I. CTDI100 Measured Dose Values at Toshiba specifications technique 120 kvp, 100 ma, 1 sec, 4 x 4mm (16 mm slice) Toshiba Aquillion 64 CT Scanner Varian tube CTDI100 (mgy) Richardson Tube CTDI100(mGy) Toshiba Specs (± 20%) CTDI100 (mgy) Phantom Center Periphery Center Periphery Center Periphery Head (16 cm) Body (32 cm) Conclusion: Both tubes deliver a value of CTDI100 to within 10% of the Toshiba Specifications shown above for the standard technique - well within the ± 20 % Toshiba tolerance. For the more-reliable phantom center measurements, the Varian and Richardson tubes delivered the same dose within 1% of each other. Measured CTDIvol values The more common representation of CT dose (see Appendix) is CTDIvol which represents a weighted average of the central and peripheral axis CTDI 100 values and which is displayed on the CT monitor for the scan technique used, namely CTDIvol = (1/3)CTDI 100 (center) + (2/3) CTDI 100 (periphery) Table II. CTDIvol Measured Dose Values in mgy at Toshiba specifications technique 120 kvp, 100 ma, 1 sec, 4 x 4mm (16 mm slice) Toshiba Aquillion 64 CT Scanner Phantom Varian tube CTDIvol Richardson Tube CTDIvol Monitor Displayed CTDIvol Toshiba Specs (± 20%) CTDIvol Head (16 cm) Body (32 cm) Midrange Midrange 12.1

3 Conclusion: Both Varian and Richardson tubes deliver a value of CTDIvol to within 3% of each other for the body phantom and within 8% for the head phantom, and both are well-within the Toshiba Specifications shown above for the standard technique, namely easily within the ± 20 % Toshiba tolerance range shown above. The agreement with the displayed CT console CTDIvol value for the body phantom is within 6% for the Varian tube, and within 3% for the Richardson tube. Likewise for the head phantom, the agreement is within -1.5 % and +7% for the Varian and Richardson tubes, respectively. The dose (CTDI) also depends on other factors, most notably the detector acquisition configuration which affects the z collimator aperture (actual beam width). The actual beam width is larger than the nominal width (over-beaming) which increases the dose significantly for narrow beams. The tube voltage (kv) obviously affects the dose. Measurements for these dose adjustment factors for both tubes are given below. Table III. Measured Aperture Dose Adjustment Factors for CTDI 100 (Body Phantom Center) Nominal Collimator setting Varian Tube Richardson Tube Toshiba Specifications 8x4mm (32 mm) x4mm (16 mm) x1mm (1 mm) Conclusion: Dependence of CTDI100 on z-collimator aperture is essentially the same for both Varian and Richardson tubes and in good agreement with published Toshiba specifications. The measured values are also consistent with our actual beam width measurements of 36mm, 19mm, and 4 mm for both tubes 7 (see CTDI-aperture, Dixon et al. Medical Physics 32(12)2005). Table IV. Measured kv dose adjustment factors (peripheral axis body) kv Varian tube Richardson tube Toshiba Spec

4 Conclusion: Near-perfect agreement with kvp variation between Varian and Richardson Tubes as would be expected (same scanner) as well as with Toshiba specifications. AMERICAN COLLEGE OF RADIOLOGY (ACR) ACCREDITATION TESTS A complete ACR accreditation test was performed for both the Varian and Richardson tubes the same required ACR accreditation tests which we perform for our Aquillion-equipped client hospitals and clinics. Typical Image Acquisition Technical Parameters Adult Head Adult Abdomen Pediatric Head Pediatric Abdomen Hi Res Chest kvp ma Time per rotation (sec) mas effective/displayed mas Scan FOV (cm) Display FOV (cm) Reconstruction Algorithm FC 23 FC 17 FC 47 FC 13 FC 86 Axial (A) or Helical (H) H H H H H # of data channels used(n) Z-axis collimation (T, in mm) A: Table increment (mm) or H: Table Speed (mm/rot) (I) Pitch (P, = (I/(NxT))) Reconstructed Scan Width (mm) Reconstructed Scan Interval (mm) Dose Reduction Techniques N/A N/A N/A N/A N/A

5 Varian Tube Displayed CTDIvol (mgy) Measured CTDIvol (mgy) N/A % Difference -4.06% 6.16% -1.55% 4.48% N/A Richardson Tube Displayed CTDIvol (mgy) Measured CTDIvol (mgy) N/A % Difference 1.94% 4.11% 6.20% 8.21% N/A Contrast to Noise Ratio (CNR) Smallest Diameter Cylinders Visible (mm) Mean CT Number Over 25 mm Cylinder (a) Mean CT Number Next to 25 mm Cylinder (b) Std Dev Next to 25 mm Cylinder (c ) Adult Head Adult Abdomen Pediatric Head Pediatric Abdomen Varian Richardson Varian Richardson Varian Richardson Varian Richardson N/A N/A N/A N/A CNR = (a-b)/c CNR Pass Criterion > 1.0 > 1.0 > 0.7 > 0.4 High Contrast (Spatial) Resolution Adult Abdomen Hi Res Chest Varian Richardson Varian Richardson Spatial Frequency Resolved (lp/cm)

6 Uniformity, Noise, and Artifact Evaluation (Using Adult Abdomen Series) Mean Noise (Std Dev) Location Uniformity Varian Richardson Varian Richardson Center Varian Richardson 3 o'clock Center - 3 o'clock No No 6 o'clock Center - 6 o'clock Visible Visible 9 o'clock Center - 9 o'clock Artifacts Artifacts o'clock Center - 12 o'clock Beam Width Measurements Detector Configuration Varian Richardson 1 x 1.0 mm x 4.0 mm x 4.0 mm Conclusion (ACR testing): The doses (CTDIvol) delivered between the Varian and Richardson tubes were comparable to better than 6 % for the clinical techniques of Adult Head, Adult Abdomen, Pediatric Head, and Pediatric Abdomen. In the image quality arena, the Varian and Richardson tubes exhibited essentially equal image quality. The scanner easily met the ACR passing criteria with both tubes. High Contrast Spatial Resolution Measurements with high resolution reconstruction algorithms 1. Nuclear Associates phantom kvp, 200 ma, 1 sec, 4 x 1.0mm, 2-stack, 100 mm FOV, FC 70 algorithm Varian Tube: 11 line-pairs/mm (0.45 mm) Richardson Tube: 11 line-pairs/mm (0.45 mm) 2. ACR phantom (Hi Res Chest technique see ACR previous data page) FC-86 kernal Varian Tube: 10 line-pairs/mm Richardson Tube: 10 line-pairs/mm Conclusion: A side-by-side comparison of the resulting phantom images showed no discernable difference in resolution between the Varian and Richardson tubes.

7 GLOBAL SUMMARY The Varian and Richardson x-ray tubes exhibited comparable performance in the Toshiba Aquillion CT scanner in both the dose and image quality arenas. The doses (CTDIvol) delivered between the Varian and Richardson tubes were comparable to better than 6 % for the clinical techniques of Adult Head, Adult Abdomen, Pediatric Head, and Pediatric Abdomen in the ACR accreditation tests. In the image quality arena, the Varian and Richardson tubes exhibited essentially equal performance in all ACR phantom tests (spatial resolution, contrast-to-noise ratio, uniformity, and freedom from artifacts). This leads to the conclusion that a Richardson Electronics ALTA750 replacement x-ray tube installed in a Toshiba Aqullion CT scanner would be indistinguishable from the standard Varian tube used insofar as the radiation dose delivered and imaging performance is concerned. On-site testing at Richardson Service Training Facility Fort Mill, SC performed by: Robert L. Dixon, Ph.D. Brian Stratmann, M.S. Certified Radiological Physicists (American Board of Radiology). References 1 R.L. Dixon et al. Report of AAPM Task Group 111 Comprehensive methodology for the evaluation of radiation dose in x-ray computed tomography, American Association of Physicists in Medicine, College Park, MD, February 2010, 2 J.M. Boone et al. AAPM report # 204 Size-Specific Dose Estimates (SSDE) in Pediatric and Adult Body CT Examinations (Cross Reference: Report 220) 3 R. L. Dixon and J. M. Boone, Dose equations for tube current modulation in CT scanning and the interpretation of the associated CTDIvol, Med. Phys. 40, (14pp.) (2013). 4 R. L. Dixon, A new look at CT dose measurement: Beyond CTDI, Med. Phys. 30, (2003).

8 5 R. L. Dixon and J. M. Boone, Analytical equations for CT dose profiles derived using a scatter kernel of Monte Carlo parentage with broad applicability to CT dosimetry problems, Med. Phys. 38, (2011). 6 R. L. Dixon and J. M. Boone, Cone Beam CT dosimetry: A unified and self-consistent approach including all scan modalities With or without phantom motion, Med. Phys. 37, (2010). 7 R. L. Dixon, M. T. Munley, and E. Bayram, An improved analytical model for CT dose simulation with a new look at the theory of CT dose, Med. Phys. 32, (2005). 8 R. L. Dixon and J. M. Boone, Stationary table CT dosimetry and anomalous scanner-reported values of CTDIvol, Med. Phys. 41(1), (5pp.) (2014). 9 R. L. Dixon and A. C. Ballard, Experimental validation of a versatile system of CT dosimetry using a conventional ion chamber: Beyond CTDI100, Med. Phys. 34(8), (2007). 10 Dose equations for shift-variant CT acquisition modes using variable pitch, tube current, and aperture, and the meaning of their associated CTDIvol Robert L. Dixon, John M. Boone, and Robert A. Kraft Citation: Medical Physics 41, (2014); doi: / Appendix: Primer on CT dose The CT scanner does not report the actual dose to a given patient. Although the value of the dose-index CTDIvol is directly associated with the CT scan performed on a particular patient (say John Smith), it represents the particular type of scan and technique factors used on Mr. Smith. However, its absolute value in mgy is not necessarily representative of the actual dose received by Mr. Smith, even though it may be recorded in his personal patient record. Rather, CTDIvol represents the dose that would be delivered to a 15 cm long plastic disk (phantom) of either 16 cm or 32 cm diameter (head or body) scanned at the same technique used on Mr. Smith, with the exception of the scan length. CTDIvol represents the dose for a scan length of only 100 mm, being calculated from CTDI100. For automatic tube current modulation 3, CTDI vol is based on the average ma over the entire scan length and CTDI 100 (a bit of a disconnect 3 ) For a body scan, the actual dose to a thin patient will be much larger than that for a thick patient for the same manual scan technique (kvp, mas, n x T, pitch, etc), whereas the reported value of CTDIvol is exactly the same for both. Thus the common value of CTDIvol reported by the scanner in mgy is

9 not likely to represent the dose to either the thin or thick patient, but rather represents the dose to their dosimetry surrogate. Namely, a 32 cm diameter plastic body phantom which is supposed to represent the body habitus of every patient who gets a body scan, whether thick or thin or whether receiving an abdomen or lung scan. The body phantom has no lungs. That being said, the CT dose phantoms are intended to represent a standard patient insofar as dose is concerned; otherwise, why have both head and body phantoms? In fact, national surveys of CT dose to the population are based on using CTDI to represent the patient dose. There is, however, a small subset of your patients for which CTDIvol is representive of the actual average dose across the central scan plane (for a 100 mm scan length). These are patients whose particular body circumference matches the attenuation and absorption of the 32 cm diameter plastic phantom (referred to hereinafter as phantom doubles). For an abdomen scan, a body phantom double would be a relatively large patient roughly a 48 waist size. Since abdomen scans typically cover a length much greater than 100 mm, the actual patient dose would be about 20 % larger than CTDIvol even for a perfect phantom double. The variation in head circumference of the patient population is typically smaller a head phantom double would wear a size 7½ hat. There is a correction to CTDI vol for patient size called SSDE 2 (Size Specific Dose Estimate) but this is not currently reported by CT scanners (see ref. 2 for details). The primary use of CTDIvol is therefore not as an absolute patient dose to the patient being scanned, but rather as a relative dose indicator to assist the CT operator in evaluating the relative dose implications of various choices of CT scan parameters available, and thus to avoid the often unnecessary use of high dose techniques. That is, the value of CTDIvol is displayed on the CT operators console after setting up a scan technique, and before initiating the scan, so it behooves the operator to be familiar with typical values of CTDIvol for routine scan techniques in order to recognize an outlier [the ACR lists such reference levels for a few procedures]. Although the reported dose CTDIvol is by inference directly associated with an individual patient, it is a very crude measure of the actual dose to that patient, so its absolute value is of secondary importance in that regard. However, the value of CTDIvol, together with other patient-specific information, may be quite useful to the medical physicist in reconstructing a more accurate (albeit still approximate) patient dose when such a dose reconstruction is specifically requested. An example would be computing a fetal dose for a pregnant patient receiving a CT scan. The CTDI paradigm does not apply for multiple, or single, axial rotations about a stationary phantom (such as brain perfusion studies in the cine mode 8 ); hence the value of CTDIvol reported by the scanner is not

10 representative of the dose even to a phantom double. DLP (Dose-Length-Product) is the other dose-related parameter reported by the scanner (in mgy.cm) which value is a measure of the total energy deposited in the phantom (and not in the patient) by the scan technique used on the patient, and is based on CTDIvol. As such, it is not further affected by the particular x-ray tube beyond the previously discussed effect on the value of CTDIvol, and needs no further consideration in this document. If CTDIvol is accurate then DLP will likewise be accurate. However, our goal is quite specific and is unaffected by the vagaries of the CT dose reporting system described above. In this study we are testing a replacement tube which is specifically designed to emulate the Varian tube it is replacing. Our dosimetric goal is merely to verify the consistency of the dose delivered (CTDI) using the Richardson replacement tube with that of the Varian tube it replaces. TOSHIBA DOSE SPECIFICATIONS: These are described only as typical dose values about which an expected deviation of ±20 % from one Toshiba scanner to another can be anticipated (all equipped with the same model x-ray tube).

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